Healthcare Provider Details

I. General information

NPI: 1043065121
Provider Name (Legal Business Name): RICHARD ALEXANDRO BUSTAMANTE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2612 S HWY 27 STE 600
CLERMONT FL
34711-6521
US

IV. Provider business mailing address

2612 S HWY 27 STE 600
CLERMONT FL
34711-6521
US

V. Phone/Fax

Practice location:
  • Phone: 407-965-0090
  • Fax:
Mailing address:
  • Phone: 407-965-0090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number31917
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: